By: Mike Barton
Many doctors recommend intensified self-management to lengthen lives and reduce long-term costs of chronic health problems associated with diabetes. But a fiercely competitive health insurance market often produces health plans that contradict appropriate medical treatment.
Increasingly, people with diabetes are coming face-to-face with denied insurance claims and health plans that leave them assuming more of the cost of their diabetes supplies – not the incentive needed to reach good glycemic control.
“The challenge now is to convince the health care providers and payers to look past the immediate cost of intensive therapy and consider the potential gains in quantity and quality of life for persons with diabetes,” says Richard C. Eastman, MD, the lead researcher on a National Institutes of Health (NIH) study that confirmed intensive therapy’s health and financial benefits.
DIABETES HEALTH Readers Tell Their Stories
Bill Orlendo, a federal park service employee and DIABETES HEALTH reader, found that Aetna Health Plans had made a change in his coverage for 1997. Changes in the brochure included removing prescription coverage for his disposable diabetes supplies, such as test strips, needles and syringes.
Orlendo’s prescription benefits, which used to cost him $5 per unit-refill for disposables, will now have to first be paid out of his own pocket. He then must submit for reimbursement, and will receive only 80 percent of the cost. So will all federal employees in California, according to Elaina Ray, an Aetna Health Plans customer service representative.
Stace Mills, an advertising sales representative, ran into trouble when he wanted to get better glycemic control by using Humalog, fast-acting insulin from Eli Lilly.
“I’ve had a lot of insulin reactions,” says Mills of his use of Regular insulin. His doctor said he could get better control and fewer adverse reactions by intensifying his therapy and using Humalog at mealtime with a long-acting insulin as a base.
It was not that easy. When Mills called Health Net, a California-based health maintenance organization (HMO), he was told he would not be covered for Humalog. Health Net said he would have to petition and prove his doctor had tried all other treatments.
“I just don’t think I should have to go through all this,” says Mills.
“It is very, very common for Health Net to wait six months with many new drugs to make sure the clinical efficacy is there,” says David Olson, a spokesman for Health Net.
Humalog has been released and widely used for nearly six months, but no date has been determined yet by Health Net for its inclusion on the company’s regular prescription list.
After weathering the process for approval and wading through contradictory information about his coverage, Mills has petitioned Health Net with his doctor and is waiting for an answer.
Key Peyton, an engineer and DIABETES HEALTH reader, lost his coverage for disposable diabetes supplies after he changed jobs and switched health care providers. He failed to read the small print in his policy.
Peyton used to be covered under his wife’s health coverage from her employer, albeit with a small additional annual fee. After he took a new job, he enrolled with CareAmerica, an HMO offered by his new employer. When he tried to purchase supplies he discovered he was not covered for any disposable diabetes supplies.
“The pure irony or ludicrousness of it is that they say, ‘We’re going to pay for the insulin, but we won’t pay for the means to deliver it into your body,'” says Peyton. “Part of the issue is that these supplies are recommended by your doctor.”
“The majority of employers don’t purchase (disposables coverage for people with diabetes),” says Lisa Freeman, a spokeswoman for CareAmerica. “They want an affordable plan.”
New laws on the books, with others on the way, seek to guarantee that affordable plans offered to employers do not leave people with diabetes without full coverage.
The Laws, They Are A Changin’
A number of states, such as New York and Florida, have passed legislation to protect people with diabetes. More are on their way. The laws guarantee that insurers cover “all medically appropriate and necessary supplies” for people with diabetes, says Loring Spolter, an anti-discrimination attorney from Fort Lauderdale, Fla.
Other laws, like the Health Insurance Portability and Accountability Act, signed by President Clinton last year, could also be meaningful for people with diabetes. The act, which will go into effect in July 1997, provides a guarantee of health care coverage for people who change jobs, says Spolter. The problem with the act is there is “no obligation to provide similar coverage,” he adds-a problem for those who need diabetes-specific coverage.
Shopping For Diabetes-Specific Health Insurance
Disposable diabetes supplies cost between $100 and $300 per month, depending on the intensity of treatment and whether or not a pump is used. Intensive therapy calls for three to four insulin doses per day for type Is and numerous daily glucose tests for all people with diabetes. The cost of the supplies could be devastating to many.
A diabetes-specific health plan is desperately needed. “People with diabetes in particular need to be wise consumers when choosing a health provider,” Spolter explains.
HMOs are the least expensive option for an employer, and some plans lack coverage for diabetes supplies. Preferred Provider Organizations (PPO) are more expensive, but usually offer more specialized coverage. PPOs allow you to go directly to a specialist, such as an opthalmologist or endocrinologist. HMOs require a doctor’s referral to see a specialist. Some HMOs scrutinize the cost and necessity of referrals very heavily.
“Avoid going into a health care setting where these problems frequently arise,” says Spolter.
Each health provider offers a variety of plans. Some HMOs have a great track record with diabetes coverage. Smart shoppers need to consider what plan is best for them, whether from an HMO or PPO.
Fight Back With Legal Advice
If a person has been denied treatment or coverage of disposable supplies by his/her provider, he/she might be able to fight back, according to Spolter.
First, patients should find out if they can petition. If so, they should request information on the appeals process in writing. All communication between the patient and provider should be in writing. Telephone conversations should be recorded on paper and sent via certified mail-as well as all letters-to the provider for confirmation of the issues discussed. Also, Spolter stresses, patients should make sure to be aware of all appeals deadlines.
Patients should also request a case manager at the health care provider whom they can deal with every time. A patient and his or her doctor will have better luck dealing consistently with one representative.
If appealing to cover necessary supplies, patients should request their doctor write a letter to the insurer stating why the desired treatment is warranted. It should also be emphasized in the doctor’s letter that the treatment is not experimental and has a proven track record, says Spolter.
If an employer’s health plan brochure does not clearly spell out its limitations or is misleading, there may be recourse for the patient. If a grievance is raised with an insurer, it is important that the grievance list all issues, because, according to the law, others will not be heard at a later date.
Spolter suggests that when patients feel they are not getting anywhere with an insurer, hiring an attorney can sometimes encourage more prompt action.
“When insurance companies receive correspondence on legal letterhead it’s amazing how frequently denials turn into approvals.”
When all else fails, patients who feel they have received poor treatment should call their state’s insurance department to make complaints and receive advice, says Spolter.
“People with diabetes need to be advocates,” he says. “Find out if your state has a law to protect diabetes patients from discriminatory treatment by their health care providers.”